An Unusual Case of Nail Gun Injury: Penetrating Neck Wound with Nail Retention in the Right Pleural Cavity

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Nail guns are tools commonly used in the building industry to drive nails at high velocity into wood or concrete. Nail guns are potentially dangerous devices, and since their introduction in the 1950s, several authors have reported traumatic injuries from nails, from gun components, or from cartridges. Many reports of nail gun accidents regard orthopedic injuries involving fingers or knees. [1-5] Other reports describe penetrating head injuries, [6-10] perforating oculocerebral injuries, [11] accidental chest and heart injuries, or suicide attempts; [6,12-14] a case of maxillofacial injury has recently appeared in literature. [15]We successfully treated a case of penetrating neck injury caused by a nail gun. The nail passed through the jugular fossa to lodge into the right pleural cavity, and no vascular or lung damage resulted.CASE REPORTA 54-year-old man was handling a nail gun and accidentally injured himself. He was using a nail gun to affix metal plates to a cement wall in his yard. After pressing the trigger he felt a sharp pain in the neck, which caused him to fall to the ground. Soon after an ambulance was called, and the patient was delivered to our hospital 30 minutes after the accident. On admission at the emergency unit, the patient was fully conscious and cooperative. Upon being asked how the accident happened, he stated that he had been struck by a piece of cement that had come away from the wall he was working on. A 3-cm long laceration wound in the jugular fossa was observed; the wound was not bleeding, it was surrounded by a minimal hematoma, and no crepitations nor bruits could be observed (Figure 1). Physical examination revealed a blood pressure of 150/80 mm Hg, a pulse of 100, and full and symmetric breath sounds. An electrocardiogram showed sinus rhythm at 94 beats/min. The patient complained of pressure sensation in the anterior region of the neck, slight dysphonia, and pain on the right side of the chest worsened by deep breaths. An intravenous infusion of normal saline was administered, the wound was dressed, and the patient received tetanus prophylaxis. Given the patient's complaint of chest pain, and to rule out foreign bodies within the depths of the wound, a chest radiograph was performed. Surprisingly the chest x-ray revealed the presence of a foreign body of metallic density (5-cm long bent nail) located in the lower rear base of the right lung at the level of the costotransverse joint of the 10th and 11th rib with no apparent pneumothorax and without modifications of cardiomediastinal image (Figure 2). A noncontrast computed tomographic (CT) scan of the chest was performed. The CT scan confirmed the presence of the nail, which was lodged within the pleural cavity; a slight thickening of the contiguous region of the pleura was evident but there were no signs of fluid or air accumulation in the pleural space (Figure 3). The CT scan excluded any damage to the neck structures, to the lung and to the endothoracic structures; no signs of bleeding or tissue disruption were observed in all the transverse sections. A control chest x-ray film was performed, and it demonstrated that the nail had changed its position, it was now projected at the level of the costotransverse joint of the eight and ninth rib (Figure 4). Fluoroscopy confirmed the nail mobility during breathing. An abdominal x-ray film and abdominal ultrasound did not show pathologic findings.

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